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t e' ;6 t' 1`+JANilOAQUIN( OZ7FFT` _ 'ZONMENTAL-HEALI'l—IJEI'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S%ZO <br /> OWNER/OPERATOR <br /> !e — CHECK if BILLING ADDRESS <br /> FACa.l1Y NAME <br /> 3g ADDREss3-7 C�(9F tlJS t( �U STOG 7b�(/ �5o21S <br /> 60 Street Number Direction Street Name C Z Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) n � / <br /> Sbn <br /> Y <br /> CITY NameE ZIP/) Street Number �p� Street v <br /> EXT. APN If <br /> PI f) 'Z Jr�—�f3 3 3 I —/O�_ CLAN,ID USE APPl1CATION <br /> 0S <br /> -� o -s moi} a s C/2�c <br /> PHONE#I EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE RE'QUESTOR <br /> REQUESTOR � <br /> CHECK If_RLLNG ADDRESS`"r <br /> BUSINESS NAME PHONE# _ E T <br /> HOME or MAILING ADDRFrSS <br /> CITY S� �)/T ;Tp7E ZIP'-fs <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T TE a FED aw . / <br /> XAPPLICANT'S SIGNATURE: DATE: 4� <br /> PROPERTY/BUSINESS OWNER❑ OPERATORI A - R OTHER AUTTIOmZFD AGENT El <br /> IfAPPLICANT is not the BILLING PARTY.Proof ofaatlrorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRO ENTAL HEALTH DEPARTMENT as soon as it is available and at the same lime it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: J V <br /> COMMENTS: PA M <br /> RECEIVED <br /> 9,19 10 OCT 18 2004 <br /> SAN JOAQUIN <br /> COUNTY <br /> NTAL <br /> ACCEPTED BY: TCheck# <br /> LOYEE#: H D P d <br /> ASSIGNED TO: EMPLOYEE#; DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Dale <br /> Payment Type Invoice# Received By: <br /> EHD 48-42-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />